PARENT/CAMPER KIT - the Cooperstown Dreams Park

6
Team Number________________ Team Name_______________________________ Week #_____
Cooperstown Dreams Park Medical Services
Camper Information
This side to be completed by parent or guardian:
Child:
Last Name _____________________First Name_________________ Sex____ DOB_______
Address_____________________________________________________________________
Parent:
Last Name __________________ First Name ___________________ Home Phone___________
Address__________________________________________________ Cell Phone ____________
Work Phone___________
Second Contact:
Last Name __________________ First Name ___________________ Home Phone___________
Address__________________________________________________ Cell Phone ___________ Relationship
_____________________________________________ Work Phone___________
If parent / guardian is coming to Cooperstown where are they staying:
__________________________________________________________Phone #______________
Health History:
Yes No
Asthma: Mild Moderate Severe Exercise induced
Allergies Please list ____________________________________
Diabetes
Seizure disorder
Heart Disease Please explain__________________________________
Other History Please explain__________________________________
Immunization History: Most recent date of immunization
MMR ___/___/___ Polio ___/___/___ DPT ___/___/___
Hepatitis B Series completed ___/___/___
Haemophilus Influenza Type b ___/___/___
Chicken Pox (Varicella) vaccine date ___/___/___
or Disease date___/___/__
A copy of immunization history is acceptable.
Please attach a photocopy of your camper’s insurance card.
IMPORTANT – THIS CONSENT MUST BE COMPLETED FOR ATTENDANCE
This health history is correct to the best of my knowledge, and the person herein described has permission to
engage in all camp activities except as specifically noted. In the event of serious illness or injury, I hereby give
Catskill Camp Services Inc. permission to provide emergency treatment and referral to a hospital in the event
I cannot be reached. I give permission to the physician selected by the camp Health Director to hospitalize,
secure proper treatment for, and to provide anesthesia, pain control, and/or other invasive treatments in the
event of severe illness or injury for my child as named above. I also give permission for my child’s personal,
protected medical information provided on this form, and any personal protected health information collected
by personnel of Catskill Camp Services Inc. to be released to any hospital and/or clinic providing treatment,
Cooperstown Dreams Park management and any insurance company representing Cooperstown Dreams
Park. This form may be photocopied for use out of camp.
Signature of parent/ guardian______________________________________
Date_______________